Leblanc M, Moreno L, Robinson OP, Tapolyai M, Paganini EP
Bicarbonate dialysate for continuous renal replacement therapy in intensive care unit patients with acute renal failure

Am J Kidney Dis (Dec) 26:910-917 1995

In acute dialysis, the hemodynamic benefits of bicarbonate over acetate are well established. Less well documented are benefits of using bicarbonate over lactate for intermittent or continuous hemofiltration. In this study, the Cleveland Clinic group attempt to make this point by comparing PD solution (Dianeal) vs. home-brewed bicarbonate dialysate for CAVHD/CVVHD. The bicarbonate dialysate was made using a regular dialysis machine, and filtered through a high-flux dialyzer membrane to remove endotoxin and bacteria. The composition of the bicarbonate and lactate-containing solutions was not completely identical, as the bicarb solution had more sodium (144 vs. 132 mM/L), less calcium (3.0 vs. 3.5 mEq/L), and less glucose (205 vs 1300 mg/dl). An average of 29 L/day of dialyste was infused

In 50 patients treated with bicarbonate CxVHD, metabolic control was excellent. In a subgroup of 13 patients treated with bicarbonate and lactate CxVHD, glucose was lower and serum bicarbonate was higher (22 vs. 18 mEq/L) in the patients during use of bicarbonate-containing solution. The authors conclude that bicarbonate-containing CxVHD solution is therefore superior to the standard lactate-containing Dianeal, although there were no hemodynamic differences identified between the two solutions. A cost analysis was done, and the home-brewed bicarbonate dialysate was cheaper.

Comment: At present there is a resurgence of interest in bicarbonate for PD solutions, as well as for CxVHD. There continues to be no good evidence for the superiority of such solutions. Apparently most patients can metabolize the lactate quite well. In hemodialysis, lactate can correct acidosis as well as bicarbonate, provided that higher doses of lactate are used. However, in units doing a large amount of CxVHD, it does make sense to prepare the dialysis solution on-line. The principal benefit appears to be a cost savings. The use of such solution in patients with liver disease has been touted as necessary, although skeletal muscle can also metabolize lactate quite well. (Daugirdas)

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Other extracorporeal therapies : Continous therapies